Which psychological factors are correlated with poor arthroplasty outcomes and are they modifiable?

 The Impact of Psychological Factors and Their Treatment on the Results of Total Knee Arthroplasty

These authors point out that psychosocial factors, including anxiety, depression, kinesiophobia, central sensitization, and pain catastrophizing, are recognized as negative prognostic factors for total knee arthroplasty (TKA) outcomes.

Depressive disorders are characterized by the "presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect function." Depression is a risk factor for adverse outcomes and objective complications after primary TKA, including mechanical failure and other implant-related complications, all-cause revisions, and medical complications. With respect to implant-related complications and revisions, it is possible that surgeons overinterpret or misinterpret examination and imaging findings in these patients because of their patient's increased pain intensity and activity intolerance, which may lead to an increased chance of reoperating on a patient who would have otherwise been treated more conservatively.

Anxiety is characterized by "excessive fear". Anxiety is a risk factor for increased pain and multiple medical complications. 

Central sensitization (CS) is defined by “an increase in the intensity of a response when an identical stimulus is presented multiple times over an extended period of time.” CS has been correlated with increased postoperative pain intensity. Importantly, centrally sensitized patients tend to present with a significantly lower Kellgren-Lawrence grade of OA.

Kinesiophobia is "an excessive and/or irrational fear of movement regarding concern for painful injury"  Kinesiophobia is associated with decreased activity, pain and decreased range of motion after TKA

Pain catastrophizing (PC) is defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience.” Patients who exhibit higher preoperative levels of PC have more pain and reduced physical activity after TKA.

The authors summarized the strength of evidence in the chart shown below.

As indicated in the right hand column, they did not find strong evidence supporting the benefit of preoperative treatment on outcome for depression, anxiety, or pain catastrophizing. They found that cognitive-behavioral therapy for kinesiophobia and duloxetine for central sensitization

may help to diminish the negative impact of these preoperative comorbidities.

Comment: It seems likely that these relationships found for total knee arthroplasty would apply as well to shoulder arthroplasty. 

This information is useful in selecting candidates that are most likely to benefit from arthroplasty and, for selected physiological factors, considering preoperative intervention.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Shoulder arthroplasty - selecting the right patient - the 4 Ps

Psychosocial factors affecting outcomes after shoulder arthroplasty: a systematic review

These authors conducted a review of sixteen article located using keywords ‘‘shoulder arthroplasty outcomes,’’ ‘‘psychosocial factors shoulder,’’ ‘‘shoulder replacement outcomes,’’ ‘‘depression shoulder arthroplasty,’’ ‘‘satisfaction shoulder arthroplasty,’’ ‘‘factors shoulder replacement,’’ ‘‘expectations shoulder arthroplasty,’’ and ‘‘predictors shoulder arthroplasty.’’

Six reviewed mental health disorders as predictors of postoperative outcome after shoulder arthroplasty. Of these, 4 found that disorders such a depression and anxiety were associated with increased risk of perioperative complications and lower final functional outcome scores. Two studies evaluated workers’ compensation status as a possible predictor of outcomes and found that patients with claims had lower satisfaction and outcome scores at final follow-up compared with those without claims. Two studies showed that preoperative opioid use was associated with lower outcome scores and overall satisfaction rate after shoulder arthroplasty. 

Three studies showed that higher patient confidence and preoperative expectations were correlated with better outcomes.

Comment: We like to point out that the outcome of shoulder arthroplasty, or any treatment for that matter, depends on for independent factors, the 4 Ps: the problem being treated, the procedure used to treat the problem, the physician rendering the treatment, and the patient reiving the treatment. This study calls our attention to the importance of the last P, the patient. Best results can be obtained by optimizing all four!

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Shoulder pain, psychological stress, perceived disability

Psychological Distress Is Associated with Greater Perceived Disability and Pain in Patients Presenting to a Shoulder Clinic.

In order to determine how psychological factors (namely depression, catastrophic thinking, and self-efficacy) affect pain and perceived disability in the shoulder, these authors studied 139 patients who completed a sociodemographic survey and elements from the The Shoulder Pain and Disability Index (SPADI),  Pain Self-Efficacy Questionnaire (PSEQ), Pain Catastrophizing Scale (PCS), and Patient Health Questionnaire Depression Scale (PHQ-2). Bivariate and multivariate analyses were performed to determine the association of psychosocial factors, demographic characteristics, and specific diagnosis with shoulder pain and disability.

Greater catastrophic thinking, higher body mass index, and being disabled or retired compared with being employed were associated with worse SPADI scores. The primary diagnosis did not have a significant relationship (p > 0.05) with the SPADI.

The authors concluded that (1) catastrophic thinking and decreased self-efficacy are associated with greater shoulder pain and disability and (2) patient-to-patient variation in symptom intensity and magnitude of disability is more strongly related to psychological distress than to the specific shoulder diagnosis.

Comment: The items in the different psychological scales are:
Pain Catastrophizing Scale 

I feel I can’t go on.

It’s terrible and I think it’s never going to get any better. 

It’s awful and I feel that it overwhelms me. 

I feel I can’t stand it anymore. 

I become afraid that the pain may get worse. 

I think of other painful experiences. 

I anxiously want the pain to go away. 

I can’t seem to keep it out of my mind. 

I keep thinking about how much it hurts. 

I keep thinking about how badly I want the pain to stop. 

There is nothing I can do to reduce the intensity of the pain. 

I wonder whether something serious may happen.

PAIN SELF EFFICACY QUESTIONNAIRE 

I can enjoy things, despite the pain. 

I can do most of the household chores despite the pain. 

I can socialise with my friends or family members as often as I used to do, despite the pain.
I can cope with my pain in most situations.

Patient Health Questionnaire Depression Scale (PHQ-2)

I have little interest or pleasure in doing things
I am feeling down depressed or hopeless

The common theme is whether or not the patient is successfully coping with the pain they are experiencing.

It is interesting to note how the multivariate analysis reduced the number of influencing factors and that BMI and working status are important associates with shoulder functional status.

This paper is illuminating. It emphasizes that if the patient emphasizes that pain is the problem, surgery may not be the solution. By contrast, if the patient is focused on their functional deficits, surgeons may have a better opportunity to improve the working of the shoulder.

We have learned to be cautious when patients give very graphic descriptions of the pain ("it feels like someone is twisting a knife in my shoulder") or suggest radical treatment for the pain ("can't you just cut the arm off?"). 

We often explain that surgery can often improve the workings of the shoulder, but is not necessarily a procedure to relieve pain. This is especially the case if the patient has had long standing pain treated with narcotic medication. 

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Consultation for those who live a distance away from Seattle.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Disability is related to more than the orthopaedic issue

Contribution of Kinesophobia and Catastrophic Thinking to Upper-Extremity-Specific Disability

While this article does not related specifically to the shoulder, there is every reason to believe that the message applies.

Among 319 patients with various hand problems, the authors sought to determine the factors that contributed to upper extremity disability as measured by the Disabilities of the Arm, Shoulder and Hand (DASH) instrument (a lower score indicates less perceived disability). They found that men had less disability than women. DASH scores differed significantly by diagnosis, marital status, and employment status. The DASH score correlated significantly with depressive symptoms, catastrophic thinking, fear of moving (kinesophobia), and pain anxiety. the authors suggest that a multidisciplinary approach to modifiable psychological factors may be helpful in lessening disability associated with upper extremity diagnoses.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

See from which cities our patients come.

See the countries from which our readers come on this post.